Community-Based Participatory Obesity Prevention Interventions in Rural Communities: A Scoping Review

Child obesity is a worldwide public health concern. In America, children from rural areas have greater odds of obesity in comparison to those from urban areas. Community-engaged research is important for all communities, particularly under-represented communities. This paper reports the results of a scoping review investigating community-engaged research in obesity prevention programs tested with school-aged children in rural America. A literature search of Medline Ovid was conducted to identify interventions reporting the results of obesity prevention interventions that promoted a healthy diet or physical activity (PA) behaviors to school-age children in rural communities of the United States (US). After title and abstract review, potentially relevant citations were further examined by assessing the full text. Each stage of review was conducted by two independent reviewers. Twelve studies met the inclusionary criteria and are included in this review. Most of the studies focused on elementary school participants (n = 7) and improving both diet and PA (n = 9). Out of the twelve studies, only five included the target audience in intervention development or implementation. The most popular type of community engagement was community participation (n = 4). This review revealed that community-engaged research is under-utilized in obesity prevention interventions tested with school-aged children in rural US communities.


Introduction
Obesity among youth is an area of increasing concern.Globally, the prevalence of childhood overweight and obesity increased from 8% in 1990 to 20% in 2020 [1].Similarly, in the United States (US), the country in which the research reported in this paper was conducted, childhood obesity prevalence among 2-19-year-olds was 19.7% in 2017-2020 [2].Further, US data reveal that obesity prevalence is not equally distributed among all groups.Although racial and ethnic disparities are well documented [2,3], geographic disparities also exist between rural and urban areas, especially among teens.This is an emerging crisis.
As of 2016, 19% of the US population and 13 million children lived in rural areas [4].In 2020, 20% of the US population was classified as rural [5], making rural obesity an important public health issue.This concern extends far beyond US borders, with 44.7% of the world's population residing in rural areas in 2018 [6].
A meta-analysis from 2015 found that children living in rural US communities have 26% greater odds of obesity in comparison to children living in urban areas [7].More recent research confirmed this disparity, although regional variability was observed [8], indicating a need for targeted intervention approaches to reflect the needs of the community.Although the risk of obesity is influenced by numerous factors, two that are under volitional control are diet and physical activity (PA) [9].While many studies have reported higher levels of PA among rural children with obesity compared to their urban counterparts [10][11][12][13][14][15][16], others have reported minor differences in dietary intake [17,18].For instance, Euler et al. showed a higher intake of whole grains, potatoes, and added sugar with every 1-unit increase in log population density [18], and Liu et al. found that rural adolescents (12.2%) had a slightly lower intake of daily fruit compared to their urban counterparts (16.5%) [12].The discrepancy between the higher prevalence of obesity among rural adolescents despite higher PA levels and similar dietary intake demonstrates the need for obesity prevention programs tailored to youth living in rural communities.
A recent scoping review examining school-based obesity prevention programs in rural communities found that most studies focused on children in elementary or middle schools, often integrating both PA and nutrition [19].However, the review did not report stakeholder or community involvement in intervention conceptualization, implementation, and/or evaluation.This is a significant oversight, given that working with the community to develop and/or adapt an intervention is an important component of intervention research [20].This approach involves the community in one or more phases of the research and can lead to important insights regarding the topic of interest [21].A meta-analysis concluded that community engagement in research was effective at improving health outcomes, particularly in under-represented groups [22].Therefore, community engagement has been identified as an essential component of interventions, particularly those designed to achieve health equity in obesity prevalence.
While various terms describe community participation in research, "communityengaged research" is the term used throughout this paper [23].Community-engaged research involves collaboration between community members and researchers to develop, implement, and/or evaluate an intervention [24,25].Key et al. [26] demonstrated that community engagement occurs at different levels, ranging from no involvement to communitydriven initiatives, with increased involvement linked to increased long-term adherence, satisfaction, and acceptance [27].Given rural populations' historically low participation rates in research [28], community-engaged research may be especially important for enhancing intervention engagement and effectiveness in rural communities.This review thus explored community engagement in obesity prevention interventions targeting school-aged youth living in rural communities in the US.

Materials and Methods
This scoping review specifically examines community engagement and target audience involvement in obesity prevention interventions developed and/or tested with school-aged children in rural communities in the US.Guided by the framework developed by Key et al. [26], the research questions for this review were as follows: (1) To what extent were stakeholders engaged in the research process?; and (2) How were the target audience (Kindergarten-12th graders) and/or their parents/caregivers involved in the research?

Data Sources
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) adapted for scoping reviews [29].
A comprehensive literature search was conducted on Medline Ovid by a professional research librarian located at the Texas Medical Center library.The search was designed to identify interventions promoting obesity prevention, healthy diet, or physical activity behaviors to school-age children living in rural US communities.MeSH headings were utilized (Obesity, Morbid or Overweight, Weight Loss, Child, Adolescent, Pediatric Obesity, Rural Health, Hospitals, Rural, Rural Population, or Rural Health Services, Primary Prevention, Health Promotion, Early Medical Intervention, Psychosocial Intervention, Internet-Based Intervention, exp Clinical Study), along with corresponding keywords, phrases, and truncated terms.Subsequently, the search strategy was then translated to Embase (Elsevier), PsycInfo (Ovid), Cochrane Library (Wiley) and Cumulated Index in Nursing and Allied Health Literature (CINAHL) Plus with Full Text (EBSCO).The detailed search strategy is outlined in Table S1.

Data Collection Procedures
The searches were conducted on 9-14 December 2021.A total of 2712 citations were identified on the subject matter.These citations were combined into an EndNote library and de-duplicated among themselves, resulting in a total of 1513 unique citations.
The inclusionary criteria for the initial review were as follows: the study must be interventional, participants must have been healthy at the start of the intervention, at least 75% of participants were between the ages of 5 and 18 years old, and at least 75% of participants lived in a rural community.Additionally, the study had to be conducted in the US and focused on obesity prevention.Conference abstracts, theses, dissertations, and proceedings were excluded.Although there is no consensus definition, rural communities are generally defined as any area that is not considered urban [30].This review included any article conducted in an area defined as rural by the authors.
This review was conducted in four stages, with articles excluded after each stage, as shown in Figure 1.Two reviewers independently conducted each stage of the review, adhering to the inclusionary criteria.Regular meetings were held to compare the results and discuss any discrepancies.
In the first stage, articles were categorized into three groups based on abstract and title review: "Yes", "No", and "Maybe".In stage 2, "No" articles were excluded, "Yes" articles were retained, and "Maybe" articles were assessed using the full article to determine inclusion.At the conclusion of stage 2, 40 articles met the inclusionary criteria.Because of the expanded focus on community-engaged research, articles meeting the inclusionary criteria were further reviewed (stage 3) to identify those that reported sufficient details on community engagement to enable reviewers to determine what research was conducted, with whom, and how.Articles lacking community involvement in study conceptualization, design, implementation, and/or evaluation, or those providing insufficient detail to assess community involvement, were excluded.At the conclusion of this stage, 12 articles were determined to provide sufficient information to address the research questions.
In stage 4, two reviewers independently extracted information from the 12 articles regarding study, intervention, and community engagement characteristics.A data extraction sheet that included definitions and extraction categories was created.Reviewers independently extracted the information and routinely met to compare extractions and resolve discrepancies.Extraction characteristics included the intervention's name, geographic location, definition of rurality, sample size, focus, goals, target audience, research design, duration, delivery location, components, theoretical frameworks employed, and research outcomes.Additionally, the implementer, level of community involvement in study design using the Key et al. framework [26] and socio-economic status (SES) of the target population were noted.
Interventions with study characteristics and outcomes published separately were cited individually but considered a single study.Consequently, one study may have multiple citations.

Results
The twelve articles that met the inclusionary criteria are characterized and described below.

Results
The twelve articles that met the inclusionary criteria are characterized and described below.
SES was defined as a measure of income in the target population.Out of the twelve studies included, nine reported on the SES of their target population.Among these, five utilized the percentage of students receiving free/reduced-price lunch as an indicator of SES [31][32][33][34]38,42].The remaining three studies relied on income to describe SES [37,39,40,43,44].
Rurality was not clearly defined in most studies.Only one provided clarification regarding its definition of rurality.Hawley et al. [45] used federal population density guidelines established in 2003 to recruit rural participants.Additionally, one out of the six schools recruited in the Askelson et al. study [42] was located in an urban county.

Intervention Characteristics
This section describes the characteristics of the interventions, including the focus, delivery method, duration, components, theoretical framework employed, and implementers.
In the "community informed" category, the researchers gathered insights from the community to guide and inform the intervention.In the "community consultation" category, the community provided feedback and advice on the proposed research plan.In the "community participation" category, community members were actively involved with the research process such as assisting in recruitment efforts and serving on advisory committees.In the "community initiated" category, the researchers responded to the community needs but without direct community involvement in the design or analysis of the research.In the "community based participatory research (CBPR)" category, community participation was emphasized in every stage of the research process.Finally, in the "community driven" category, the community started and led the research, seeking researcher support.
Examples for each of the remaining six levels are presented in Table 3 and a figure representing the balance between researcher and community involvement is presented in Figure 2.

Review Question #1: To What Extent Were Stakeholders Engaged in the Research Process?
For the purposes of this review, "stakeholders" were defined as community members involved in intervention development, adaptation, and/or implementation.The "target audience" (i.e., those for whom the intervention was designed to affect behavior) was defined as school-aged children living in rural US communities.Therefore, to explore this

Review Question #1: To What Extent Were Stakeholders Engaged in the Research Process?
For the purposes of this review, "stakeholders" were defined as community members involved in intervention development, adaptation, and/or implementation.The "target audience" (i.e., those for whom the intervention was designed to affect behavior) was defined as school-aged children living in rural US communities.Therefore, to explore this question, we identified various stakeholders involved in the research, focusing on schoolaged children (level 1), followed by their caregivers (e.g., parent or caregiver) (level 2), intervention implementers (e.g., teachers or school staff if school-based) (level 3), and/or the larger community (e.g., broader community members not included in levels 1-3 (level 4).Stakeholders were categorized by varying levels to capture the degree to which members of the target audience themselves or their parents were included in the research.These can be seen in Table 4.  [26].The most frequent level of community engagement was community participation, where four out of the twelve studies actively involved community members in the research process, such as providing feedback on the proposed intervention, developing/modifying the intervention material, and delivering the intervention [31,39,40,43,44,46].Three studies were classified as CBPR, where stakeholders collaborated in the planning, implementation, and evaluation of the intervention [32,33,38,42].Additionally, three studies fell into the community consultation category where feedback and advice were sought, including insights into barriers that need to be addressed and current behavioral patterns [34,45,47,48].Two studies were classified as community-informed, utilizing surveys and focus groups to gather input on proposed research and baseline characteristics [35][36][37].
Table 5 displays these levels for each article along with more specific details regarding stakeholder involvement in the participatory design, utilization of the target audience or stakeholders in the development of the intervention, and the stakeholder level.Only five out of 12 interventions included the target audience [34][35][36][38][39][40]42], while six included parents/caregivers [32][33][34][37][38][39][40]47,48].Of these, one included the target audience only [35,36], one included parents/caregivers only [47,48], and one included both the target audience and parents/caregivers only [34].In studies including the target audience in the participatory design of the intervention, students participated in assessing baseline data and in the strategic planning, implementation, and evaluation of the intervention.Additionally, students took part in focus groups or surveys to provide insight into baseline behaviors or perceptions of current institutional guidelines.When parents or caregivers were included in the participatory design, they provided feedback on proposed research plans, evaluated baseline data, and selected and implemented interventions.They also participated in focus groups to identify concerns, barriers, and current behaviors regarding childhood obesity.

Discussion
This scoping review examined the characteristics of obesity prevention studies conducted with school-aged children in rural US communities.While many were school-based, only 12 of the 40 studies involved some form of community-engaged research.Community engagement is crucial for designing effective interventions [22], particularly for addressing significant public health issues, such as the obesity disparity identified among children in rural US communities [7,8].Given that the rural population in the US is growing [5], there is an even greater need to develop interventions specifically designed to address the needs, preferences, and challenges faced by school-aged children in rural communities.
Despite the urban-rural childhood obesity disparities varying across countries [49], and the increasing trend of urbanization worldwide [50], community-engaged research remains crucial on a global scale.By actively engaging with communities, researchers can prioritize local knowledge and expectations, ensuring that interventions are culturally relevant and tailored to address the specific barriers of children in each context [51].
Rural communities often face unique challenges that should be considered when designing an obesity prevention intervention.These challenges include poverty [52][53][54][55], transportation issues [56], limited access to healthcare services and resources [53,57], readily available access to healthy, affordable foods [58,59], and safe places to play [60] in some, but not all communities.Community-engaged research can offer insight into the specific challenges faced by a community and offer unique suggestions for ways to overcome them.
Our review of community-engaged research in obesity prevention interventions in school-aged children living in rural communities identified only 12 studies that met the inclusionary criteria.While there is agreement that involving the community in research that affects them is important [23], it is not often reported in the literature.A systematic review examined both randomized clinical trials and non-randomized comparative effectiveness trials and found that out of a possible 371,159 trials, only 23 papers reported communityengaged research of some type, meaning that less than 1% of trials conducted in 2011-2016 included the community [61].Therefore, our finding is not surprising.However, when examining publication dates of the articles included in the review reported here, there was a visible increase in the number of articles reporting utilizing community-engaged research (pre 2000 vs. 2000-current).
Recent research with teens living in rural communities revealed they perceived that being physically active was much easier in a rural community than locating healthy food options outside the home, an important insight when developing obesity prevention interventions for teens in rural US communities [62].As an example, these findings suggest that obesity prevention interventions for these teens would need to emphasize maintenance of existing PA behaviors while helping them identify ways to find healthy food options away from home.The importance of community-engaged research in the creation of personally relevant interventions was also supported by insights obtained from 8-to 10-year-old Black/African American girls and parents who participated in an online obesity prevention intervention [63]; the findings clearly revealed that community-engaged research led to an intervention perceived as personally relevant and meaningful to both the girls and their parent/caregivers.These findings emphasize the need to conduct community-engaged research with the target audience in order to ensure that the interventions address issues perceived to be important to them.This is critical for the development of effective interventions in that personally relevant interventions are more likely to be appealing [64,65], leading to greater engagement and exposure to intervention content.Ultimately, greater engagement is more likely to result in behavior change, particularly when the intervention content addresses issues of personal importance.
Our review of the literature identified some improvements in health-related behaviors, environment, and psychosocial factors, such as improved knowledge or attitudes.However, only two out of seven studies [37,43,44] reported improvements in at least one anthropometric measure at the final follow up.Interestingly, community engagement was associated with improved dietary intake, with three out of five studies showing positive results [35][36][37]46].These findings suggest that community engagement can be a helpful tool for promoting positive behavior change in youth.Future work is needed to investigate the types and levels of community engagement for promoting changes in specific youth behaviors like diet and physical activity.It could be that the type and level of community engagement may need to be tailored to the specific behavior being addressed.
Our research aligns with findings from other studies that show inconsistent results regarding improvements in anthropometric measurements in response to obesity interventions.A recent systemic review found only 14 out of 33 interventions led to a reduction in BMI or BMI z-score [66].However, this review also highlighted that involving key stakeholders improved intervention effectiveness.Similarly, a systematic review of obesity interventions in Hispanic children showed that those utilizing a community-based framework were more likely to reduce BMI compared to those not involving a community-based approach [67].This review also reported that six out of ten studies improved fruit and vegetable consumption and reduced intake of calories, fat, and sodium.Notably, all six studies promoted the engagement of parents or the community in the activities.
Based on these findings, we anticipated significant improvements in anthropometric measures and dietary habits due to the involvement of key stakeholders in the interventions analyzed.However, the lack of significant improvement in anthropometric measurements may suggest that achieving such changes in rural populations might be more challenging compared to other groups, such as Hispanic children [67].
Further research is needed to examine how to use community-engaged research to develop interventions designed to improve anthropometric measurements in children and youth living in rural communities.For example, work is needed to understand who to include when attempting to understand factors that impact body weight, body fat, and other anthropometric variables in youth, i.e., children or teens, parents/caregivers, and/or other members of the community.This research would contribute to greater insight regarding how to best utilize community engagement to understand these factors in youth and how to best utilize this information to develop interventions that "fit" within the rural context.
The underrepresentation of parents/caregivers in intervention design is another noteworthy finding.The need to involve parents or caregivers in interventions designed to impact the behavior of youth is well documented [68,69], particularly since parents are the gatekeepers of the home environment [70].Parent's choices and behaviors influence early childhood diet-related behaviors [71,72].The involvement of parents or caregivers in changing a child's behavior is further supported by the Family Systems Theory [73,74], which recognizes the family as a complex social system, with parents and children having an effect on each other's behavior [75].Thus, it is concerning that only three of the studies included in this review involved both parents or caregivers and the children targeted by the interventions.This suggested that future obesity prevention interventions for children in rural communities in the US should explore ways in which to involve parents or caregivers in intervention development or adaptation.By involving parents/caregivers in intervention development, we can create a more holistic approach that addresses the family unit as a whole.
Although there are many different ways and opportunities to conduct communityengaged research with children and their parents or caregivers, careful consideration should be given to the type of information needed, the status of intervention development, and or other considerations, such as the timeline, budget, and how much or little information already exists for a specific audience.Close consideration of the Key et al. categories [26] can facilitate the selection of the specific type of research needed to meet the project needs.For example, large national databases exist that can provide information in the beginning stages of research with a community to develop an understanding of their existing status regarding particular behaviors, such as the dietary status of particular groups [76] (community consultation).Other researchers may choose to conduct research with the community itself to identify particular issues from their perspective prior to intervention development (community consultation) [62].In this type of research, interviews, focus groups, and other techniques, such as photovoice [77], can be useful techniques.To adapt an intervention or determine the relevance of an existing intervention for a particular population, the Delphi Technique could be used.A recent project convened a Community Advisory Board to review an existing intervention developed more than a decade ago; the Delphi Technique, combined with Key Point Summaries, resulted in high levels of both engagement and involvement [78] (community participation).There is no right or wrong way to conduct community-engaged research; however, it is important to perform some level of communityengaged research to understand issues from the communities' perspective [26].
Finally, most of the studies used a quasi-experimental design, making it difficult to assess intervention effects.Future obesity prevention studies with school-aged children living in rural US communities should prioritize involving the target audience and their parents or caregivers in intervention design or adaptation, followed by assessment using a fully powered randomized design.In addition, future research should also explore the mechanisms of change within these interventions.This would help move the field forward by conducting robust research aimed at identifying strategies to reduce obesity risk in schoolaged children in rural US communities.It would also help understand how interventions that influence behavior can inform future iterations and improve overall effectiveness.
This review highlights the need for future research on childhood obesity prevention in rural US communities to prioritize community-engaged approaches.Community-engaged research not only benefits intervention design but also fosters intervention sustainability [26,[79][80][81].By actively involving community members in research, we can help build trust and capacity within the rural communities and create a sense of ownership and investment in the intervention's success.This can lead to increased community support and adoption of intervention, ultimately promoting long-term behavior change [79,80].

Limitations
As in any study, there are limitations to this research.First, few of the studies included in this review provided a specific definition of rurality; instead, they simply reported that the school or community was located in a rural area.This lack of a standardized definition may have resulted in the inclusion of articles involving populations not traditionally classified as rural.Additionally, the term "rural" may have inadvertently excluded studies with a rural community that were not explicitly labeled as such.Second, although studies reported using theoretical frameworks, few specified how these theories were applied in intervention development.Thus, it was difficult to determine if the mentioned theories played a role in guiding the program development and implementation.Third, although we extracted data on the use and outcomes of community-engaged research in obesity prevention interventions tested with rural youth, we did not collect data on the outcomes of interventions that did not utilize community-engaged research.This information would be useful for those interested in determining the effectiveness of community-based interventions among rural youth.Fourth, comparing the outcomes of the interventions included in the review was challenging because of the variety of reported outcomes and the frequent reporting of outcomes not identified as primary or secondary.Further, the most common research design was quasi-experimental, leading to concerns regarding confounding variables [82].Systematic reviews and meta-analyses of randomized controlled trials are needed to better understand the efficacy or effectiveness of community-engaged research in this context and to examine the type and intensity of community-engaged research with outcomes.

Conclusions
This review revealed that community-engaged research is underutilized in obesity prevention interventions tested with school-aged children in rural U.S. communities.Of the 40 studies reviewed, only 12 involved some form of community engagement, and only three included both children and their parents or caregivers.Community-engaged research can be a valuable tool for understanding issues of personal importance to under-represented populations and developing interventions that reflect their needs, preferences, and expectations.With rural adolescents showing greater risks for obesity even while reporting high levels of PA, the underlying causes of obesity in this population are not well understood.Involving the target audience or relevant stakeholders, such as parents or caregivers, in the development and implementation of interventions for this under-served population may result in more tailored interventions addressing their barriers/concerns, ensuring cultural relevance, and leveraging community resources effectively.Further research examining the efficacy of obesity prevention interventions developed for children in rural US communities using community-engaged research is needed.Prioritizing community engagement may enable researchers to develop effective and sustainable solutions to address childhood obesity in rural US communities, ultimately empowering communities to take charge of their health and well-being.

Figure 1 .
Figure 1.PRISMA 2020 flow diagram for search results and screening outcomes.

Figure 1 .
Figure 1.PRISMA 2020 flow diagram for search results and screening outcomes.

Figure 2 .
Figure 2. Different levels of community and research engagement in research.Adapted from Key et al. [26].

Figure 2 .
Figure 2. Different levels of community and research engagement in research.Adapted from Key et al. [26].

3. 5 .
Research Question #2: How Were the Target Audience (K-12th Graders) and/or Their Parents/Caregivers Involved in the Research?
AIM: Adapted Version of Intervention Mapping; PA: physical activity; PE: physical education; SHI: School Health Index.

Table 3 .
Researcher and community engagement in interventions.
Community-Based Participatory Research Researchers and community jointly identify a need, determine how to address it, develop the intervention, assist in recruitment, evaluation and/or interpretation Community-Driven/Community-Led Community coalition identifies a problem, determines how to address it; may consult with a researcher for advice or questions, but community drives the research and makes decisions Adapted from Key et al. [26].Nutrients 2024, 16, x FOR PEER REVIEW 12 of 23

Table 5 .
Participatory design of interventions.
a Level 1: school-aged children; Level 2: parents or caregivers; Level 3: those implementing the intervention, such as teachers or school staff; Level 4: the larger community not included in Levels 1-3; AIM: Adapted Version of Intervention Mapping; CBPR: community-based participatory research; SHI: School Health Index.